GW1-2022-06944_Well Construction - GW1_20220601

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
JACOB MESSICK �14.'WATER-'ZONES .
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
A - 4252 ft. ft.
NC Well Contractor Certification Number 151 OUTER-CASING foesniulti=cased-ivells'OR T INER if a licable.' '
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0.0 ft. 43.0 ft- 6.0 SCH 40 PVC
16.INNER CASING'ORTUBING e6thermal closed-loo"i
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0.0 ft. 45.0 ft. 2.0 in* SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: FROM TO • DIAMETER I SLOT SIZE THICKNESS MATERIAL '
❑Agricultural ❑Municipal/Public 45.0 ft. 50.0 1" 2.0 in. .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18:GROUT „.
❑lt'r( ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 40.0 ft' PORTLANDBENTOWE SLURRY
[EMonitoring ❑Recovery 0.0 ft. 43.0 ft' PORTLANDBENTONITE SLURRY
Injection Well: ft. ft.
El Aquifer Recharge ❑Groundwater Remediation
rl19 SAND/GRAVEL PACK(if a'fliable =
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
El Aquifer Test ❑StormwaterDrainage 44.0 ft' 50.0 ft. 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
��
❑Geot erma (ClosedLoop ❑Tracer "20.1)RILT;ING IibG attechaddihonabsheets if ueces"sa' �" ��n
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DESCRIPTION color,hardness,soil/mck type,grain size,etc.
0.0 ft- 28.0 ft. TAN SILTY SAND
4.Date Well(s)Completed: 04/28/22 Well ID# MW-2D 28.0 ft. 30.0 ft• SANDY CLAY
5a.Well Location: 30.0 ft. 50.0 1" SILTY SAND
SPEEDWAY- 8187 ft. ft. (r°-77.Wk. P`��.-tip.
Facility/Owner Name Facility ID#(if applicable)
14477 US - 17 HAMPSTEAD 28443 ft. ft.
Physical Address,City,and Zip ft. ft.
PENDER z1REMARKS
County Parcel Identification No.(PIN)
BENTONITE SEAL 40:0v44?t)FEETI
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: -
340 21' 54.50" N 770 42' 49.35" W m Mto-'A 05/10/22
6.Is(are)the well(s): OPermanent or []Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or TlNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the ofthis record has been provided to the well owner.
repair under#21 remarks section or on the back ofthis form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Ovef in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 50.0 (ft.)
For multiple wells list all depths ifdifferent(example-3@200'and 2@100� Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 10.0 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level is above casing,use"+"
11.Borehole diameter' 12.0/5.875 (in) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AUGER/MUD ROTARY
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test:
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018